[Downloaded free from http://www.eurjdent.com on Thursday, February 14, 2019, IP: 115.178.250.

173]

Original Article
Smartphone application as an aid in determination
of caries risk and prevention: A pilot study
Veerale Panchal1, Deepa Gurunathan1, A. K. Shanmugaavel1

Correspondence: Dr. Veerale Panchal 1

Department of Paediatric and Preventive Dentistry,
Email: veerale60193@gmail.com Saveetha Dental College, Saveetha University, Chennai,
Tamil Nadu, India

ABSTRACT
Objective: To assess the dietary and oral hygiene pattern before and after the usage of cariometer app. Materials and Methods: Dietary
score recorded by cariometer was assessed for 7 days for preschool children in the age group of 2–6 years. The frequency of
brushing and mouth rinsing was assessed before and after the usage of app. Paired t‑test was conducted to compare the dietary
score, brushing frequency, and rinsing frequency pre and post the use of the app. Results: There was a significant improvement in
the dietary pattern followed by the patients at the day 7 as compared to day 1. About 90% of children brushed twice at day 7 of the
use of cariometer. There was a significant increase in the frequency of rinsing after meals at day 7 as compared to day 1 of the use of
cariometer. Conclusion: There was a significant improvement in the dietary pattern and the oral hygiene habit after the use of app.

Key words: Diet score, oral hygiene, tooth brushing

INTRODUCTION Stephan curve demonstrates the variation in pH of

The prevalence of dental caries in India among
preschool children varies from 19.2% to 71.1%. [1]
However, according to the National Oral Health
Survey 2002–2003 documented an average prevalence
of 40.5% in the state of Tamil Nadu and 40%‑60% in
the country.[1] According to the National Oral Health
Survey 2002–2003, the caries risk for children aged
2–5 years was higher by 2%.[2]
According to the WHO, the multifactorial nature
of dental caries is related to the presence of
microorganisms, fermentable carbohydrates in
the diet, particularly when consumed frequently,
susceptible teeth, and early stage of development.
In the causation of the caries, there is a dynamic
balance between the caries risk factors and protective
factors.[3] This balance is maintained by the continuous
remineralization and demineralization process which
maintains the integrity of the tooth structure.[4]
Access this article online
Quick Response Code:
oral cavity which is a result of the acid produced
by the bacteria and buffering capacity of saliva.[5]
Repeated exposure of the tooth pH below the critical
pH level (5.5)[5] increases the rate of demineralization
due to the lack of calcium and phosphate. Thus,
maintaining the pH of the oral cavity above the
critical pH plays an important role in the prevention
of demineralization.[5]
Dietary factors and food choices affect the oral pH,
thereby being important determinants in causation
of dental caries.[6,7] Parent’s cultural norms is vital in
influencing the child’s dietary habits[8] as well as with
the changing ethnicity, there is more predisposition
to consumption of fast food that leads to the increase
in the consumption of cariogenic food. [8] The
association of dental caries to excessive sugar intake
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

Website:
How to cite this article: Panchal V, Gurunathan D, Shanmugaavel AK.
www.eurjdent.com
Smartphone application as an aid in determination of caries risk and
prevention: A pilot study. Eur J Dent 2017;11:469-74.
DOI: 10.4103/ejd.ejd_190_17

© 2017 European Journal of Dentistry | Published by Wolters Kluwer - Medknow 469

[Downloaded free from http://www.eurjdent.com on Thursday, February 14, 2019, IP: 115.178.250.173]
Panchal, et al.: Cariometer: A click against caries
has been affirmed by an expert panel of the World
Health Organization, whose members reviewed the
strength of evidence linking dietary factors to caries
in 2003.[2] The panel reported the increased risk of
caries associated with frequent and total intake of free
simple sugars. It also reported a decrease in the risk
of caries related to consumption of hard cheeses and
use of sugar‑free chewing gum. It is also observed that
mouth rinsing after cariogenic food consumption has
a protective effect against dental caries.[6,7] Another
study by Díaz‑Garrido et al. showed more frequent
sucrose consumption increases the cariogenicity of
Streptococcus mutans biofilm.[9] Another study by
Manju et al. demonstrated a decrease in S. mutans level
with supplementary oral hygiene measures along with
tooth brushing.[10]
Dietary counseling is the primordial level in the
prevention of dental caries caused due to dietary
influences. Together with the use of fluoride, basic
rinsing practice and reducing the frequency of intake
of sugar are essential for caries prevention.[11,12] It
is essential for dental professionals to routinely
screen the patients and assess the role of diet in
caries risk management.[13] The present tech‑savvy
generation is governed by the use of apps for the easy
of performing day‑to‑day basic tasks. Many of these
apps aid individual behavioral change toward health
and fitness. Previous study has been done to evaluate
the effectiveness of android application for physical
fitness and weight loss.[14] As a technological initiative
in the field of dentistry, “Cariometer” an android
application has been developed by the authors in
which day‑to‑day diet consumed is entered with
the corresponding time of food consumption. This
application is available for android phones and
can be downloaded from the internet from Google
App Store https://play.google.com/store/apps/
details?id=gowtham.example.com.dentalcare. The
app gives a diet score based on the cumulative mean
of the cariogenic score as given by Palmer et al. in
2010.[15] Parents can enter the food consumed along
with the time of consumption choosing from the list
given in the app. The total dietary score is given by
the app which is cumulated with addition of new
data as and when it is entered during the day. The
oral hygiene practice such as brushing rinsing and
flossing is also entered which reverses the increase in
score to zero. The application evaluates the dietary
and oral hygiene practice of the child and graded
as excellent, average, or bad. The application also
gives an alarm when the dietary score is in the bad
or average category and oral hygiene habit is not
470
practiced. Cariometer also contains a feature where
total score of the day and the cumulative score for
the week or any customized date can be obtained.
The report obtained can be mailed to the dentist
who can advise on the dietary pattern and oral
hygiene practice of the child. Thus, this app benefits
both the child and parent in prevention of dental
caries. Cariometer is in the process of obtaining
patency from the Indian Patency Act with application
no 201641035345.
To study the effectiveness of this application, a pilot
study was conducted with the aim of monitoring the
diet and oral hygiene habits. The null hypothesis of
the present study states that the use of cariometer will
have no improvement in the diet and oral hygiene
habit.
MATERIALS AND METHODS
The ethical approval was obtained from the
ethical committee board of Saveetha dental college
(STP/SDMDS16PED3‑A). This was a pilot study
conducted in the Department of Pediatric and
Preventive dentistry in Saveetha Dental College,
Chennai. Parents of children in the age group of
2–6  years  (mean: 5.5  years) were included in the
study. A total of 150 children visiting Department of
Pediatric and Preventive Dentistry of Saveetha Dental
College for dental treatment between November 1,
2016 and January 31, 2017 were recruited to participate
in the study based on convenience sampling. Parents
of medically fit children were included. Parents
using android phones were included in the study.
Parents of all the children were asked about the
dietary and oral hygiene habits and were introduced
to cariometer application. They were asked to enter
daily consumption of food as and when it was
consumed by the child in the application for 7 days.
Data of participants were included for analysis only
when complete entry of food consumption and oral
hygiene instruction were entered by the parents. Due
to incomplete data obtained from some children,
a final of 132 children were included in the study.
All the children included for the study had similar
cultural norms.
Description of cariometer application
Cariometer can be downloaded and installed in the
smartphone operating on android system. In the
first page of Cariometer, registration of each child
can be completed with name and age. The parents
can enter the food items by selecting from the list
European Journal of Dentistry, Volume 11 / Issue 4 / October‑December 2017
[Downloaded free from http://www.eurjdent.com on Thursday, February 14, 2019, IP: 115.178.250.173]
Panchal, et al.: Cariometer: A click against caries
of different categories of food which includes:
milk/cheese, beverage, sweet/chips/chocolate/
bubblegum, fresh and dry fruits/nuts/vegetables,
rice/oats/cereals/wheat/bread, nonvegetarian
side dish/rice, fresh juice/ice‑cream/milkshake,
and medication. The oral hygiene practice including
rinsing after meals, brushing, and flossing can also
be noted in the app.
The parents were asked to use cariometer app in
which they had to enter the daily food consumed at
the same time the food was consumed. Parents entered
for the child during school hours by assuming the
child has consumed food given by the parents during
the lunch and/or break time. They were also asked to
note the rinsing brushing or flossing after meals by
selecting from the oral hygiene tab. Cariometer gives
a dietary score every time the food and oral hygiene
habit was entered. This score was cumulated over the
day into a single score for the day. The app also gives
pictorial representation and dietary reinforcements
for the consumption [Figure 1]. Of healthy food after
entering each food item. After consumption of all
the meals for the day, parents were asked to mail the
daily report which contained the dietary score and
oral hygiene habit as given by the app. The parents
continued using this application for 7 days. The mail
report contained the rinsing habit post the use of the
app as well as the brushing frequency for each day that
the patient followed after using the app. All children
were given dietary instructions and modifications in
the diet to prevent caries post 7 days based on the
dietary pattern that was followed by the children.
These children using cariometer were further followed
up to evaluate the effectiveness of the application in
a long‑term longitudinal study.
Figure 1: Pictorial representation of diet score as given by the app for
the patient
European Journal of Dentistry, Volume 11 / Issue 4 / October‑December 2017
Statistical analysis
The data obtained were recorded on a spread sheet
and their respective mean and standard deviation (SD)
were calculated. The adjusted mean was calculated by
IBM SPSS statistics for Windows, version 22.0 (IBM
Corp, Armont, NY, USA). These were the mean of the
covariant and analysis of covariance (ANCOVA) was
conducted for the dietary score obtained in the app at
day 1, day 4, and day 7. Paired t‑test was conducted to
compare the pre‑ and post‑dietary score, the brushing
and rinsing frequency. A statistical significance level
was set at P < 0.05.
RESULTS
Of the 150 participants, the data of 132 parents
were considered for analysis. However, there was
attrition of the sample in the present study. Three
parents did not report at the end of 7 days due to
disinterest in participating in the study, four parents
missed entering data for 1 or 2 days and 11 parents
did not enter data at the time of consumption of
food. Due to incomplete data obtained from parents
of 18 children, a final of 132 children were included
in the study.
The Normality tests Kolmogorov–Smirnov and
Shapiro–Wilks tests results reveal that variable
(Diet Score) follows normal distribution. Therefore, to
analyze the data parametric methods were applied. To
compare the diet score between time points repeated
measure ANCOVA test for repeated measures was
used. To analyze the data SPSS (IBM SPSS Statistics
for Windows, Version 22.0, Released 2013, IBM Corp.
Armonk, NY, USA) were used. Significance level is
fixed as 5% (α = 0.05).
The mean diet score on day 1 was 1.51 with SD of
0.244. The mean diet score on day 4 was 0.83 with SD
of 0.276. The mean score on day 7 was 0.07 with SD
of 0.143 [Table 1].
The ANCOVA showed a significant decrease in the
dietary score obtained at the end of 7 days as compared
to day 1 [Table 1 and Figure 2].
There was a significant improvement in the brushing
frequency, with approximately 90% of children
brushing twice a day after the use of the app
[Table 2 and Figure 3]. None of the children rinsed
after the meals before the use of the app. This was
significantly increased to approximately 90% children
rinsing after every meals [Table 3 and Figure 4].
471
[Downloaded free from http://www.eurjdent.com on Thursday, February 14, 2019, IP: 115.178.250.173]

Panchal, et al.: Cariometer: A click against caries

Table 1: Comparison of diet score between different time points

Diet score n Mean SD 1st quartile Median 3rd quartile P
Day 1 132 1.51 0.244 1.4 1.5 1.7 <0.001
Day 4 132 0.83 0.276 0.7 0.8 1.0 <0.001
Day 7 132 0.07 0.143 0 0 0.1 <0.001
SD: Standard deviation

Table 2: Comparison of brushing frequency before

and after use of the application
Brushing frequency: Day 1
Once, Twice, Total,
n (%) n (%) n (%)
Brushing frequency: Day 7
Once 14 (10.6) 0 14 (10.6)
Twice 118 (89.4) 0 118 (89.4)
Total 132 (100.0) 0 132 (100.0)

Figure 2: Comparison of 3 days diet score

Table 3: Comparison of frequency of rinsing after
meals before and after use of application
Rinsing after meals: Day 1
No, n (%) Yes, n (%) Total, n (%)
Rinsing after meals: Day 7
No 14 (10.6) 0 14 (10.6)
Yes 118 (89.4) 0 118 (89.4)
Total 132 (100.0) 0 132 (100.0)
DISCUSSION
Technology has become a pivotal part of our day
today system. With the introduction of android
system, it has been bought to our fingertips. In this
regard, cariometer has been developed to bring caries
prevention to the finger tips.
Similar study have been done using mobile application
to make a dietary assessment based on the type of food
consumed showing the calorie intake,[16] however no
application measures the dietary score based on the
weighted mean on the cariogenic risk of individual
food items. This provides the uniqueness for the
present study.
Caries risk assessment tool has been developed
previously. American academy of pediatric dentistry
has developed CAT to monitor the caries risk based
on the exposure to fluoride, clinical findings, presence,
or absence of caries.[17]
Another system used to assess the caries risk of
the patient is cariogram, which was developed by
Bratthall and Hänsel Petersson in the year 2004. This
examines the caries risk based on the multifactorial
nature of the dental caries.[18]
These previous applications developed are however
for professional use which cannot be used by
the common man for the primary level of caries
prevention. In this regard, to increase the cooperation
and involvement of patients in caries prevention,
this application was developed. Cariometer can be
useful on day‑to‑day basis for caries prevention. The
present study is the first of its kind done using android
application estimating the caries risk based on the diet
and oral hygiene. Diet counseling has always been the
primordial level of caries prevention.[3,19] In the regular
diet counseling, physical presence of the dentist is not
feasible as a constant reminder and reinforcement.
However, with the introduction of the cariometer, this
can be made possible thus increasing the efficacy of
diet counseling. This application aids in prevention
of the caries at the primordial level of development
if started using from an early age.
Parents of children who participated in the study
were the people who came for treatment. Hence, the
knowledge of parents regarding oral health could
be a decisive factor in usage of the app. This could
have influenced the results. However, since the app
is new initiative evaluation before and after the usage
of the app with controlled follow‑up is essential.
Hence, this hospital‑based study provides valuable
information on the usage of application. There was
a significant improvement in the dietary habits
before and after the use of cariometer. This can be
because cariometer allows a detailed accounting of
the food consumed giving the cumulative cariogenic
score for the corresponding diet consumed. Thus,
giving the patient knowledge of the cariogenic food

472 European Journal of Dentistry, Volume 11 / Issue 4 / October‑December 2017

[Downloaded free from http://www.eurjdent.com on Thursday, February 14, 2019, IP: 115.178.250.173]
Panchal, et al.: Cariometer: A click against caries
Figure 3: Comparison of brushing frequency pre and post the use of
cariometer
consumption. Second, a pictorial representation of
the cariogenic status of the teeth aids as an alert
and helps in the maintenance of diet. There is also
a feature which alerts the user if the cariogenic food
consumption exceeds the optimal limit. This acts as a
reminder to decrease the cariogenic dietary intake. Not
only will it provide a check on the dietary intake, but
also on the increase in the consumption of protective
food. Increase in the consumption of protective food
aids in increase in the good score, thereby acting as
reinforcement. The diet diary followed in the app
was according to article given by Palmer et  al.[15]
A standard 7 days diet was followed as shown by
previous studies.[20]
The significant improvement on the oral hygiene habit
as shown by the patients can also be contributed to
the recurrent alarm which acts as a reinforcement and
a reminder to rinse and brush. This application also
includes the effect of rinsing and other oral hygiene
practices on the caries score further reinforcing oral
hygiene habits. This promotes the development of
basic cleaning measures among the patients. It allows
the patients to monitor the diet daily as well as weekly.
It provides a personalized caries management system
for the patients.
According to a previous study by Damle et al.,
evaluating the effectiveness of supervised tooth
brushing and oral health education on oral hygiene
showed significant improvement in the oral hygiene
habit. [6] These results correlate with the present
study showing improvement in the oral hygiene by
reinforcing oral hygiene habits. Study by Nizel and
Papas[20] shows the effectiveness of dietary counseling
by maintaining diary on the prevention and control of
European Journal of Dentistry, Volume 11 / Issue 4 / October‑December 2017
Figure 4: Comparison of rinsing after meals pre and post the use of
cariometer
dental caries. These results coincide with the present
study showing improvement in the dietary score by
maintaining a proper dietary record.
Cariometer gives an idea for the caries risk the patient
is subjected to. It does not include the multifactorial
nature of dental caries and focus only on dietary
and oral hygiene aspects. Additional supplemental
chair side use of caries activity test can be beneficial
to determine accurate caries risk. Cariometer is a
preliminary step to bring caries prevention to the
finger tips.
Cariometer encompasses certain limitations which
were encountered during the duration of the
study. The food list present needs to be updated
incorporating the food items from all the cultural
diversity. Furthermore, the person needs to be present
all the time to reply to the mail, increasing the need
for more manpower. This is in the process of being
overcome by developing an autogenerated reply
system which can send remarks to the parents based
on the dietary score. Further, diet counseling can be
obtained personally by the dentist on the dental visit.
All the limitations are in the process to be overcome
in the further version of application.
The present study uses the 7 days method to record
the diet which will include the school going days
as well as the holidays where the children tend to
have increased snacking. However, a bias can be
encountered in the present study while recording
the diet consumed in school. This could be overcome
in the further studies by encouraging the teacher to
enter the food consumed by the children during the
school hours.
473
[Downloaded free from http://www.eurjdent.com on Thursday, February 14, 2019, IP: 115.178.250.173]
Panchal, et al.: Cariometer: A click against caries
Another limitation of the present study is small sample
size with lesser duration. Further continuation of the
present study with long term follow‑up, and larger
sample size is needed to achieve the correct correlation
and have more sustainable results. A randomized
controlled trial comparing cariometer with the
conventional diet diary will be ideal study design to
be followed and obtaining more conclusive results.
The present study is being continued in the institution
with the randomized controlled trial design having a
long‑term follow‑up. Furthermore, the application of
present study in the population with varying cultural
diversity, will aid to check vitality of the application
to different population.
Cariometer successfully gives an approximate estimate
of the caries risk based on the diet and reinforces oral
hygiene habits. It is an attempt to utilize technology
to every household to aid in the prevention of dental
caries.
CONCLUSION
Cariometer is used to assess the quality of dietary
habit and frequency of oral hygiene habits and also
aid in its improvement by providing reinforcement
using recent technological advances.
Acknowledgment
Acknowledging Mr. Gowtham Ashok for his assistance
in the coding for the app.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Dixit  A, Aruna  DS, Sachdev  V, Sharma  A. Prevalence of dental
caries and treatment needs among 3‑5 year old preschool children in
Narmada, Gujarat. IOSR J Dent Med Sci 2015;14:97‑101.
474 European Journal of Dentistry, Volume 11 / Issue 4 / October‑December 2017
2. Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton‑Evans G, et al.
Trends in oral health status: United States, 1988‑1994 and 1999‑2004.
Vital Health Stat 11 2007;248:1‑92.
3. Chour  GV, Chour  RG. Diet counselling  –  A primordial level of
prevention of dental caries. IOSR J Dent Med Sci 2014;13:64‑70.
4. Featherstone JD. Dental caries: A dynamic disease process. Aust Dent
J 2008;53:286‑91.
5. Stephan RM. Changes in hydrogen‑ion concentration on tooth surface
and in carious lesions. J Am Dent Assoc 1940;27:718‑23.
6. Damle  SG, Patil  A, Jain  S, Damle  D, Chopal  N. Effectiveness of
supervised toothbrushing and oral health education in improving
oral hygiene status and practices of urban and rural school children:
A comparative study. J Int Soc Prev Community Dent 2014;4:175‑81.
7. Cappelli DP, Mobley CC. Dental caries and associated risk factors. In:
Prevention in Clinical Oral Health Care. 1st ed. St. Louis, MO: Mosby
Elsevier; 2008. p. 65‑7.
8. Kant AK, Graubard BI, Schatzkin A. Dietary patterns predict mortality
in a national cohort: The National Health Interview Surveys, 1987 and
1992. J Nutr 2004;134:1793‑9.
9. Díaz‑Garrido  N, Lozano  C, Giacaman  RA. Frequency of sucrose
exposure on the cariogenicity of a biofilm‑caries model. Eur J Dent
2016;10:345‑50.
10. Manju M, Prathyusha P, Joseph E, Kaul RB, Shanthraj SL, Sethi N, et al.
Evaluation of the effect of three supplementary oral hygiene measures
on salivary mutans streptococci levels in children: A  randomized
comparative clinical trial. Eur J Dent 2015;9:462‑9.
11. Mobley C, Marshall TA, Milgrom P, Coldwell SE. The contribution of
dietary factors to dental caries and disparities in caries. Acad Pediatr
2009;9:410‑4.
12. Moyniham P, Lingstrom P, Rugg‑Gunn AJ, Birkhed D. The role of
Dietary control. In: Fejerskow O, Kidd E, editors. Dental Caries: The
Disease and its Clinical Management. Oxford: Blackwell Munksgaard
KJ; 2003. p. 222‑41.
13. Karolinska I, Susanna A, Lars GP, Helena D, Soder B, Gunilla N, et al.
Effect of combined caries‑ preventive methods: A systematic review
of controlled clinical trials. Acta Odontol Scand 2004;62:163‑9.
14. Laing BY, Mangione CM, Tseng CH, Leng M, Vaisberg E, Mahida M,
et al. Effectiveness of a smartphone application for weight loss
compared with usual care in overweight primary care patients:
A randomized, controlled trial. Ann Intern Med 2014;161:S5‑12.
15. Palmer CA, Kent R Jr. Loo CY, Hughes CV, Stutius E, Pradhan N, et al.
Diet and caries‑associated bacteria in severe early childhood caries.
J Dent Res 2010;89:1224‑9.
16. Pendergast FJ, Ridgers ND, Worsley A, McNaughton SA. Evaluation
of a smartphone food diary application using objectively measured
energy expenditure. Int J Behav Nutr Phys Act 2017;14:30.
17. Council on Clinical Affairs. Guidelines on caries risk assessment
and management for infants and children and adolescent. AAPD
2002;37:15‑6.
18. Bratthall D, Hänsel Petersson G. Cariogram – A multifactorial risk
assessment model for a multifactorial disease. Community Dent Oral
Epidemiol 2005;33:256‑64.
19. Mirjalili N, Hassan M, Karbasi A, Farahman J. Comparing tap water
rinse with tooth brushing and sugar free chewing gum: Investigating
the validity of a popular belief. J Dent Oral Hyg 2014;6:22‑5.
20. Nizel AE, Papas AS. Dietary counselling for the prevention and control
of dental caries. In: Nutrition in Clinical Dentistry. 3rd ed. Philadelphia:
W.B. Saunders; 1989. p. 277‑308.